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Five Myths About the Plan to Close the India Street Clinic – Explained and Debunked

City Hall was packed tonight as around 60 local residents showed up to weigh in on what they’d like to see in the City of Portland’s municipal budget for the upcoming fiscal year.

The budget is a big deal. Between July 1, 2016 and June 30, 2017, our municipality will spend around $328 million. This money is what funds our local public schools. It’s the parking garages. The cops and the firemen. The sidewalks and the building permits. The library and the local public health services.

Yet, of all the the thousands of expenditures that the City of Portland is scheduled to make in the year ahead, almost everybody who testified tonight spoke to the same topic: the proposed closing of the India Street clinic.

To give you some background, in addition to the healthcare services provided by the hospitals and other private providers throughout the city, folks in Portland currently have a few public healthcare options. These include a clinic that the City operates on India Street and also several clinics that Portland Community Health Center (PCHC), a rapidly growing, federally recognized agency, operates throughout the area.

Pointing to the success of the PCHC, Jon Jennings, Portland’s City Manager, has proposed that the City shut down the India Street clinic. Why, he questions, should the City spend our scarce municipal tax dollars helping to provide services that the Feds seem more than happy to fund on their own?

Not one to belabor bureaucratic processes, Jennings has proposed completely shutting down the India Street clinic within a matter of months. Several members of the Council have quickly hopped on board, and the City Council’s Finance Committee, the body responsible for honing the first draft of the budget, has already eagerly green-lighted the proposal.

Fully in support of Jennings, Councilor Belinda Ray issued her own statement several days ago, which can be found here.

As tonight made evident, many people in the Portland community who depend on the clinic have been left feeling scared and angry, me included.

To make matters worse, there seems to be a ton of misinformation out there about what’s actually happening here.

If you read the City Manager’s statements along with those of certain city councilors, it would be easy to come away with the impression that nothing too terrible is going on. The responsibility for providing the services currently available at India Street, they tell us, is simply shifting hands from the City of Portland to the PCHC. All we’re talking about is a shift on paper, a change in who will foot the bill, and where they’ll operate out of. Nothing is changing, they assure us, in the amount or the nature of care that will be provided.

This narrative simply isn’t true. Below, I’ve attempted to identify five beliefs that seem to underlie the proposal that has been brought by Mr. Jennings and to explain why I believe that these notions are all false.

Here goes:

1. The India Street clinic is just an ordinary facility providing primary care that could be replaced easily.

The India Street clinic consists of a handful of different programs under one roof that all share resources with each other, including a drop-in STD Clinic; Positive Health, which currently provides care to 220 people who are HIV Positive; and the Needle Exchange, which last year worked with 808 intravenous drug users. In addition, the Portland Community Free Clinic, an independent nonprofit staffed largely with volunteer doctors and nurses, also shares the facility alongside the municipal programs.

Combined, around 18 people work at the clinic, as well as many volunteers, and well over a thousand people receive care there every year. Total operating costs are substantially over a million dollars a year, the vast majority of which comes from federal funding sources, not the City.

These are tough populations to work with. Queer street kids. Folks living with HIV. Hard drug users. Portland’s massive population of working people who lack accessible primary care coverage. By all accounts, the staff at India Street does an amazing job of caring for all of these people.

At the hearing tonight, we heard a trans man share about how, even though most healthcare facilities terrify him, he feels comfortable and safe at India Street. We heard from recovered heroin addicts who survived their periods of illegal opiate use because the Needle Exchange was there to offer them clean supplies, a helping hand and access to Narcan, the miracle solution capable of saving a person’s life mid-overdose.

Most impressively, we heard from a number of men who are HIV Positive, yet have had their “viral load” suppressed to the point of being undetectable. Whereas once HIV was a death sentence, today 95% of patients at India Street live to see their virus become undetectable, compared to only around 60% at facilities nationwide.

Healthcare in the United States today is a disaster. Enormous overhead. Pill mill pain clinics. Basic procedures that leave patients with years of medical debt. By all accounts, the India Street clinic is an oasis, a bright spot of human kindness where lives are saved and damaged people can heal.

India Street didn’t get here over night. It took years of strategically recruiting great staff and carefully building relationship with patients. I’m sure many tough lessons were learned along the way. But, by all accounts, today, India Street is an unusually high quality facility. It seems very unlikely that recreating a facility of this caliber from whole cloth could ever be an easy or quick undertaking.

If we truly care about everybody in our community, we need to think critically about what we can do to respond intelligently to the widespread epidemics of poverty and heroin that are plaguing our community, and the India Street clinic offers a powerful example of what such a response looks like. Whatever we do, we need to be careful that we don’t simply destroy this gem in the fabric of our city.

2. The clinic poses a heavy and debilitating fiscal burden on the City of Portland.

It’s clear why Jennings is advising that the city get out of the healthcare business. Money.

Under federal statues, independent “federally qualified” health centers, like PCHC, are able to collect much higher reimbursement rates from MediCare and MaineCare, enabling them to be solvent to the point that they don’t rely on local municipalities almost at all.

On the other hand, in order for the India Street clinic to stay open and remain competitive for federal grants, it would need heavy updates to its computer infrastructure and electronic medical records system, an expense estimated at well over a hundred thousand dollars.

But let’s take a step back and put things in perspective. While the clinic could certainly use an infusion of capital, the bare minimum that the municipality would have to pay to keep the lights on and the doors open has been estimated at around $300,000. In the context of a projected municipal budget totaling around $328 million, that’s around a thousandth of Portland’s municipal expenditures for the year ahead.

I understand that there are many other things competing for City dollars, but god damn it. Out of every thousand dollars that the City spends, they can’t afford to spend a buck or two on public healthcare and Portland’s heroin epidemic? Are you kidding me?

At the hearing tonight, we heard from a handful of people from the PCHC board of directors who showed up to defend their program, and it was heartening to hear that India Street isn’t the only capable public healthcare provider in the city.

But the problem isn’t that PCHC is incompetent. The problem is that it does something different than India Street.

Without going too deep into the history of Federally Qualified Health Centers (FQHCs), my understanding is that these institutions exist primarily to provide as many people as possible with “primary” care. Everything would be better, the theory says, if everybody, no matter how rich or poor they are or what language they speak, had a doctor they could call their own. FQHCs offer facilities with open doors where anybody in the Portland community can come in, fill out a few forms, enroll as a patient and connect with a provider whom they can schedule regular checkups with.

For a lot of people this might be totally adequate. It’s probably true that everybody should have a primary care physician, and personally, I like data. It doesn’t freak me out to think that somebody working for the federal government could look up my social security number and find out what clinic I go to. If anything, keeping track of this stuff seems like a really practical way to make sure that everybody’s covered.

At the same time, it also makes sense to me that some patients might have needs that couldn’t adequately be met by this kind of institution. In fact, based on what I heard tonight at the hearing, lots of the people who are struggling most intensely with today’s most serious public health epidemics, like chemical dependency and sexually transmitted diseases, don’t always feel comfortable going to their primary care physician with their problems.

Such people, especially those folks who don’t have a stable place to call home, need drop-in centers where they can get a clean needle or an STD test without ever giving more than their name. India Street provides that kind of service beautifully in ways that, by all accounts, feel comfortable, safe and inviting to even the most tortured souls.

I’m not an expert. Maybe, in time, PCHC could develop and implement services more like those currently offered at India Street? But for right now, at least, they aren’t. Even if everybody currently receiving care at India Street were offered a relationship with a primary care physician at PCHC, from my perspective, that still wouldn’t do away with the need for India Street.

We’re kidding ourselves if we think that PCHC is truly prepared to become a viable substitute for India Street. PCHC has no experience operating an HIV clinic or a needle exchange and doesn’t have a proven track record of providing care specifically to LGBTQ people, just to name a few things, and their staff is stretched so thin that patients frequently have to wait weeks to see physicians. In the face of so much untreated illness and suffering, the last thing we should be doing is shutting down any top notch public healthcare facility.

Finally, one of the biggest indicators for me that PCHC is not prepared to pick up the slack is that very few of the people who staff India Street’s Needle Exchange and Positive Health programs are even interested in going to work at PCHC.

Many of the India Street staff that I’ve had the pleasure of meeting are free thinking activists who are passionate about working directly with affected populations in independent ways. As one friend told me recently, a few of them are probably more likely to become organic farmers than go to work in a sterile institutional environment like PCHC. The opportunities there just don’t feel like they’re even in the same line of work.

4. The plan currently in front of the Portland City Council allows plenty of time and support for such a transition to occur.

This is by far the most egregious lie that’s been presented to our community.

It’s true that the history of social services in Maine has always been full of mergers and acquisitions, single houses that grow into entire agencies and alliances that emerge as disparate groups unite together. In principle, there’s nothing too fantastical about imagining a world in which the services currently being provided at India Street are housed within an independent nonprofit that isn’t under the aegis of the municipality.

But let’s think for a second about what a healthy organizational transition process would look like. For one thing, we’d want to work with experts to think critically about the complex organism that is the clinic, carefully accounting for all its different moving parts.

For another, we’d want to have a lengthy participatory decision-making process, so community members could weigh in and work together to craft a collective vision for the kind of clinic that we’d all like to have. With enough foresight and careful planning, who knows what we could accomplish?

But, that’s not the proposal that brought scores of terrified people into City Hall to testify tonight. The proposal that Mr. Jennings has brought to the Council isn’t a “transition plan” at all. It’s a death sentence.

The proposal on the table doesn’t offer the India Street staff much more than a few months to find new jobs before they all get fired, the lights go out in the clinic and the doors get locked.

Mr. Jennings proposes we shoot first and ask questions later. Once it’s clear that the clinic is shutting down, then, and only then, will we actually take the time to work out the details of how to create new, non-municipal services, services which are unlikely to be all that equivalent to what’s being lost, at least for the foreseeable future. Who knows where the money for the new programs will come from? Where will they be located? Who will oversee the process? None of this has really been hammered out yet.

If we were talking about transitioning something trivial, this approach might be okay. But we’re talking about difficult and complicated programs that play significant roles in keeping hundreds of people alive. Mr. Jennings is shamelessly proposing we do something that throws the health of the most vulnerable people in our community into jeopardy.

The truth is that, for all the reasons described above, PCHC is not currently set up to offer the kinds of services that are being provided at India Street. Perhaps, in time, PCHC could launch a Needle Exchange and HIV Clinic, but as things stand currently, they don’t really have enough time to secure sufficient grant funding and community approval to guarantee that such programs will be able to launch in time.

There’s also little reason to have faith in their ability to even enroll and engage all the patients from India Street in the kind of primary care services that PCHC is currently set up to provide.

At the hearing tonight, we heard experts in the field share about what’s happened in cities around the country that have closed their free clinics, including most recently what happened in Biddeford when they closed their municipal clinic. None of these stories end well. Patients inevitably get lost and fall out of the system. They lose care. End up in the emergency room. Die.

In lieu of a solid plan, it’s hard to see cutting all the City money for India Street as anything but rushed, reckless and incredibly dangerous, especially given how severe a threat opiates, STDs and extreme poverty pose to our community.

Personally, I think there’s a good chance that our best option will turn out to be keeping India Street as a municipal service, but I’m open to exploring what a potential organizational transition might look like, and I think a lot of the folks currently involved with the clinic might also be open to considering some reasonable ideas.

But, for right now at least, there just isn’t anything solid enough to consider. Every day, hard drugs and STDs put Maine into crisis. It’s our duty as responsible citizens to make sure that the groups working so hard to address those challenges aren’t also in crisis. And this plan is the dictionary definition of putting such services into crisis.

5. The plan is already a done deal, and stopping it is a hopeless battle.

Nothing’s over until it’s over. To date, Mayor Strimling and Councilors Costa, Hinck and Thibodeau have expressed support for the idea of extending the life of the clinic for at least another year, and not moving ahead with any kind of transition until a detailed, concrete proposal has been put on the table.

I think it’s worth noting that, even among the councilors who support the closure, most of the arguments in favor of ending the clinic are not being made along culturally conservative lines.

Lots of Americans don’t believe tax payers should be responsible for buying syringes for opiate users or paying for people having extramarital sex to get STD tests. This debate would be really different if the councilors were blatantly disagreeing with the mission of the India Street clinic along those sorts of lines.

But, for the most part, they aren’t.

Instead they’re pointing to the fact that many cities of our size have already closed their public health clinics, relegating all forms of healthcare to the private sector.

India Street’s no different they say. And it’s so expensive! PCHC is more than capable of just taking everything over. Everything’s in place for a smooth transition. Let’s do it!

The problem with this argument is that, as I’ve attempted to outline above, none of those assessments are true. India Street’s a unique place that plays a vital role in the Portland community that cannot be easily replaced. All things considered, it’s really not very expensive. PCHC is nowhere near ready to provide equivalent services, and even if they were, there’s only the barest bones of a transition plan, much of which looks infeasible, and nowhere near enough time to pull it off without seriously hurting people.

If you care about the mission of the India Street clinic, I really don’t see how you can maintain a clean conscience and support the plan to close it so abruptly.

All people in Portland deserve to be healthy and get the care they need, and it’s on our entire community to see that they get it. Portland is for everybody!